Assess the following authorization form against the Privacy Rule criteria and determine if any element(s) is(are) missing. Modify the document by adding language to incorporate any element(s) found missing.

PINE VALLEY COMMUNITY HOSPITAL

AUTHORIZATION TO RELEASE HEALTH INFORMATION

Patients Name: ______________________ Date of Birth: _________________________________

Patients Social Security Number: _____________________________________________________

I hereby authorize Pine Valley Medical Center to release to the following:

Name: __________________________________________________________________________

Address: ________________________________________________________________________

Documents to be released are: _______________________________________________________

From Date of Service: _____________________________________________________________

Purpose for record request is: _______________________________________________________

I understand that applicable laws may prohibit redisclosure of this information, but that PVMC will not be liable or responsible for any redisclosure that takes place after the information has been released.

I understand that I will not be denied treatment if I refuse to sign this authorization.

I understand that I am entitled to a copy of this authorization.

I understand that the information will be handled confidentially in compliance with applicable state and federal laws.

I have read and understand the nature of this release.

__________________________________________

Patients Signature/Legal Representative ______________________

Date

__________________________________________

Witness ______________________

Date

Resource

Rinehart-Thompson, L. A. 2017. The HIPAA Privacy Rule: Part 1. Chapter 10 in Fundamentals of Law for Health Informatics and Information Management, 3rd ed. M. S. Brodnik, L. A. Rinehart-Thompson, and R. B. Reynolds, eds. Chicago: AHIMA